101 ARW Confined Space Assessment

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Facility #

• Squadron/Office Symbol

• Location and description of space to be entered:

• Pictures:

  Media

• Purpose of entry:

• Tasks or operations to be performed:

• Is the space large enough and so configured that an employee can bodily enter and perform assigned work?

  Yes

  No

  N/A

• Does the space have limited or restricted means for entry or exit (for example: tanks, vessels, silos, storage bins, hoppers, vaults, and pits)?

  Yes

  No

  N/A

• Is the space not designed for continuous employee occupancy?

  Yes

  No

  N/A

Permit-Required Confined Space Determination (one or more of the following)

• Contains or has a potential to contain a hazardous atmosphere.

  Yes

  No

  N/A

• Contains a material that has the potential for engulfing an entrant.

  Yes

  No

  N/A

• Has an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or by a floor which slopes downward and tapers to a smaller cross-section.

  Yes

  No

  N/A

• Contains any other recognized serious safety or health hazard.

  Yes

  No

  N/A

Additional Considerations

• Can the space be locked or sealed to prevent entry?

  Yes

  No

  N/A

• Is it possible to eliminate all hazards without anyone entering the space?

  Yes

  No

  N/A

• Will the space be entered less than four times per year?

  Yes

  No

  N/A

• The space described below has been determined to meet the criteria in 29 CFR 1910.146 and AFMAN 91-203 for classification as:

  Select Permit Required (occasional entry, permit required for each entry) Permit Required (frequent entry, Master Entry Plan) Non-Permit Required

  • Permit Required (occasional entry, permit required for each entry)
  • Permit Required (frequent entry, Master Entry Plan)
  • Non-Permit Required